in Norway Surveillance
E. faecium Enterococcus spp faecalis
3.7 Basis for a new plan
Action plan for preventing antibiotic resistance 2000–2004
After half a year of intensive effort, the interdiscipli nary Hareide-utvalget (a committee charged with studying the matter) presented a proposal for a national action plan to prevent antibiotic resistance in 1999. In March of 2000, the fiveyear plan was launched by five ministries. The plan was a pioneer ing effort in Europe. Its crosssectoral perspective was especially important. Professionals and admin istrators from a number of sectors came together and agreed about the challenges.
The primary objective of the Government’s action plan to prevent antibiotic resistance (2000–2004) was “to preserve antibiotics as good and effective medicines against infectious diseases in the 21st century by counteracting the development and spread of antibiotic resistance”. The goals were to acquire better knowledge about the use of antibiot ics, the occurence of resistant microbes in humans and animals and in food products and the environ
ment, and the causes of the development and spread of resistant microbes, to improve the use of antibiot ics and to improve the control of communicable diseases.
The Norwegian Ministry of Health and Social Affairs (later renamed the Ministry of Health and Care Services) has had the primary coordinating responsibility for the plan, but the Ministry of Agriculture, the Ministry of Fisheries, the Ministry of the Environment and the Ministry of Local Government and Regional Development have also been involved in the work. An interministerial steering committee has provided annual summaries of the status in accordance with the plan.
The following eight primary target areas were set up in order to achieve the goals of the plan: 1. Surveillance of antibiotic resistance 2. Surveillance of the use of antibiotics 3. Prescription
4. Communication with and information to the general public
5. Control of communicable diseases
6. Microbiological diagnostics and determination of resistance
7. Management and supervision 8. Research, development and study
In addition, highpriority measures were established in order to achieve subtargets in each target area. The Government’s action plan to prevent antibiotic resistance (2000–2004) has played a key role in the efforts to prevent antibiotic resistance in Norway. In consultation with the interministerial steering committee, the Norwegian Institute of Public Health wanted a broad evaluation of the original plan and wanted to propose strategies and measures for the ongoing work. On this basis, the Norwegian Institute of Public Health’s conference for the
Type of antibiotic 2001 2002 2003 2004 2005 2006 2007 Florfenicol 109 205 154 111 202 302 139 Flumequine 7 5 60 4 28 7 18 Lincomycin/ Spectinomycin (1:2) 50 67 Oxytetracycline 12 11 45 5 8 0 19 Oxolinic acid 517 998 546 1035 977 1119 406 Total 645 1219 805 1159 1215 1478 649 Table 3.13
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evaluation and continuation of the Government’s Action plan to prevent antibiotic resistance
(2000–2004) was held on 14 and 15 September 2004 at Olavsgård Hotel in Akershus County. The conference was organised by the Norwegian Institute of Public Health’s committee for the prevention and combating of antibiotic resistance
(Antibiotikakomitéen), which is an advisory working group in the fields of medical microbiology, infec tious diseases, pharmacy, general medicine, veterinary medicine and public health that makes efforts to prevent and combat antibiotic resistance in Norway.
In 2004, it could be ascertained that there had been a negative trend internationally with the increasing spread of resistance and fewer and fewer suitable antibiotics for use in difficult cases. In Norway, we still have a satisfactory situation, but especially the increasing occurence of methicillinresistant golden staphylococcus (MRSA) both in hospitals and in the primary health service gives cause for concern. A number of the measures in the plan were fully imple mented; some were well underway, while others had not yet been initiated. Several measures have become permanent and are incorporated into the individual agencies’ normal efforts. Networks have been established among professionals.
The Norwegian Institute of Public Health estab lished a committee for preventing and combating antibiotic resistance. The committee took special responsibility for carrying on the efforts against antibiotic resistance. The Ministry maintained sepa rate allocations earmarked for the measures in the plan even though the plan period was formally over. The plan specified over fifty measures in eight target areas. Some of the more important measures that have been implemented under this action plan are: The Norwegian surveillance system for resistance
in microbes (NORM) has been established as a permanent personal health data filing system. Norway provides high quality data to the
European Antimicrobial Resistance Surveillance System (EARSS).
Surveillance of resistance in the HIV virus has been established as a part of the Norwegian Surveillance System for Communicable Diseases (MSIS).
The Norwegian Prescription Database, which also includes antibiotics, has been established as a permanent personal health data filing system.
The Centre for Antibiotic Treatment in The Primary Health Service has been established. The public health campaign for better use of
antibiotics (“All Children catch Ear Infections”) has been implemented.
The Norwegian Working Group on Antibiotics has been formalised and provides guidance, standardi sation and quality assurance to the medical microbiological laboratories.
The Veterinary Medicine Centre for Producer independent Information on Medicines (VETLIS) has become a permanent measure.
A surveillance system for resistance in microbes from animals and food (NORMVET) has been established.
Need for further efforts
The first Norwegian action plan to prevent antibiotic resistance was a pioneering effort and resulted in a number of new measures. The battle, however, is far from being won, so the work must continue. The key measures are the surveillance of the resistance situation and the use of antibiotics and the measures to reduce the consumption of antibiotics and prevent spread.
Surveillance antibiotic resistance
Surveillance of antibiotic resistance is defined as continual, systematic gathering, analysis and interpretation of data on microbes’ resistance conditions and their significance for public health for use in the planning, implementation and evalua tion of public health measures. Surveillance can help increase our understanding of the relationship between the use of antibiotics and measures to control communicable diseases on the one hand and the development of resistance on the other. The surveillance can therefore also be utilised in the evaluation of the measures in this plan. In addition, the surveillance can influence the choice of medi cine in empirical treatment (i.e. treatment before the microbe and its resistance pattern are known). Surveillance is therefore a key measure that must continue in this plan period. Relative to the year 2000, the situation is much better now. Extensive surveillance is being conducted through the government personal health data filing systems MSIS and NORM and, for animals, NORMVET. These can be further improved. It will also become increasingly important to develop good surveillance of resistance against antiviral medicines to combat important diseases, such as HIV infection and influenza. Furthermore, the individual hospitals
68 must have good systems for the internal detection of
special resistance problems.
Surveillance of the use of antibiotics
Since the use of antibiotics is the most important cause of the development of resistant microbes, it is fundamentally important to have an overview of the amount and pattern of consumption in Norway. Surveillance of the use of antibiotics is defined as continual, systematic gathering, analysis and interpretation of data on the use of antibiotics for people and animals for use in the planning, imple mentation and evaluation of measures for the optimisation of this use. Surveillance can also help increase our understanding of the relationship between the consumption of antibiotics and meas ures to control communicable diseases on the one hand and the development of resistance on the other. The surveillance is therefore a key measure that must continue in this plan period. Relative to the year 2000, the situation is much better now. Extensive surveillance is conducted through the Norwegian Drug Wholesaler Database and the Norwegian Prescription Database. Especially the latter provides very precise data about the pattern of consumption, even though a diagnosis is currently lacking in the individual prescription. Better surveillance of the consumption by the individual health care institutions is needed, however, prefer ably down to the department level. In addition, the surveillance of antibiotics given to animals and fish must be improved.
Better use of antibiotics
In Norway, as elsewhere, more antibiotics are still used than necessary. Antibiotics are sometimes used on incorrect indications and incorrect antibiot ics, incorrect doses and incorrect treatment periods are chosen. On the basis of consideration of the individual patient or the resistance situation, the use of antibiotics is not good enough.
Especially in the treatment of upper respiratory tract infections outside hospitals, there are great opportunities for a more correct use of antibiotics. Whereas the largest total amount of antibiotics is used outside hospitals, especially for rather banal infections of ears, throat and sinuses, the largest
amount per patient is used in hospitals. More or less all patients with serious infections such as blood poisoning, extensive surgical wound infections, serious types of pneumonia, cerebrospinal meningi tis, inflammations of the heart valves and not least
infections in patients with reduced immune de fences (patients with transplanted organs, leukae mia, HIV infection, etc.) are treated with antibodies. In addition, patients with a number of less serious infections (infections of the skin, bones, joints and abdomen, gastrointestinal infections, moderate pneumonia, etc.) are also treated in this way. Finally, antibiotics are often used for the prevention of surgical wound infections. Hospitals typically have a large consumption of broadspectrum medications that entail considerable risk of the development of resistance. This is especially true of intensive care units, but also departments of surgery, internal medicine and pediatrics.
Since the year 2000, there has been increasing awareness among health personnel of the impor tance of a sensible use of antibiotics. Nevertheless, a continued effort is necessary. A change in the incorrect use of antibiotics requires measures aimed at those who prescribe antibiotics, i.e. doctors, dentists and veterinarians. Pharmacists, nurses and other groups of health care personnel will also play important roles.
Attempts to change the prescribers behaviour must occur simultaneously with attempts to influence the general public’s knowledge, attitudes and behaviour. The situation is in fact such that the general public themselves can exert considerable influence on the doctor or veterinarian to prescribe antibiotics for their child or pet. Thus, measures are needed to increase the general public’s knowledge of antibiot ics and resistance, to change their attitudes to the use of antibiotics, to influence their behaviour with regard to asking the doctor for antibiotics for themselves and their children, and to influence their behaviour with regard to becoming more skilful at alleviating the suffering of sick children.
Cover picture:
E. coli with extended-spectrum betalactamase (clavulanate-inhibited
betalactamase) next to a sensitive control strain
The picture is by Karianne Wiger Gammelsrud and Arne Høiby, Department of Bacteriology and Immunology, Division of Infectious Disease Control (avd. SMBI), the Norwegian Institute of Public Health
Published by:
Norwegian Ministry of Health and Care Services Public institutions may order additional copies from: Norwegian Government Administration Services Distribution Services
E-mail: [email protected] Fax: + 47 22 24 27 86
Publication number: I-1136 E
Print: Lobo Media 09/2008 - Impression 250 Design: Rudi Risan, Lobo Media